DHA Case No. FCP 221117 (Wis. Div. Hearings and Appeals Feb. 23, 2026) (DHS) ↓ Download PDF Residential care services provided through Family Care MCOs may be authorized only when a member’s long-term care outcomes cannot be cost-effectively supported in the member’s home, or when a member’s health and safety cannot be adequately safe guarded […] Read more

DHA Case No. MPA 220854 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF When considering a prior authorization request, DHS must consider medical necessity, appropriateness, cost, alternatives, and whether the service is an effective and appropriate use of available services. In this case, the petitioner requested prior authorization for a power […] Read more

DHA Case No. CWA 220576 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF DHS has an obligation to ensure the IRIS program meets certain federal standards, such as the requirement that settings where home and community-based services are provided have the qualities listed in 42 C.F.R. §441.301(c)(4). In this case, the […] Read more

DHA Case No. CWK 221161 (Wis. Div. Hearings and Appeals Feb. 9, 2026) (DHS) ↓ Download PDF Respite care is a service covered by the Children’s Long-Term Support Program (CLTS), but respite care payments are not allowed to a parent or a primary caregiver in the participant’s household. In this case, the agency discovered that […] Read more

DHA Case No. HMO 220800 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF Personal care worker (PCW) services for an activity are not medically necessary if the member can perform the activity safely with the use of an assistive device. In this case, the petitioner requested 24.5 hours per week of […] Read more

DHA Case No. CWA 220708 (Wis. Div. Hearings and Appeals Feb. 2, 2026) (DHS) ↓ Download PDF IRIS participants are assigned budgets based on their Long-Term Care Functional Screens, which they must generally stay within (or request a budget amendment). In this case, petitioner received 10 home-delivered meals per week due, in part, to chronic […] Read more

DHA Case No. FCP 220551 (Wis. Div. Hearings and Appeals Jan. 9, 2026) (DHS) ↓ Download PDF MCOs may not deny a service that is reasonable and necessary, and in an amount, scope, and duration needed to cost-effectively support the member’s long-term care outcomes. In this case, the petitioner lived in a 1-2 bed adult […] Read more

DHA Case No. FCP 220498 (Wis. Div. Hearings and Appeals Jan. 5, 2026) (DHS) ↓ Download PDF Services provided through the Family Care program must be cost-effective. In this case, the petitioner lived at an AFH and attended a nearby adult day service program that proved very beneficial. When he moved to a different AFH, […] Read more

DHA Case No. CWA 221013 (Wis. Div. Hearings and Appeals Feb. 25, 2026) (DHS) ↓ Download PDF IRIS funds approved through the budget amendment process must be used for the requested service and cannot be transferred to a different service or service type, or a different provider type. In this case, the petitioner was enrolled […] Read more

DHA Case No. CWK 221068 (Wis. Div. Hearings and Appeals Feb. 20, 2026) (DHS) ↓ Download PDF A “Notice of Action” must be provided to CLTS participants at least fifteen days before a reduction or termination of services, which participants have the right to appeal. In this case, the petitioner’s respite services were terminated effective […] Read more

DHA Case No. FCP 219708 (Wis. Div. Hearings and Appeals Feb. 17, 2026) (DHS) ↓ Download PDF To be eligible for full services through an MCO, a Family Care member must require a “nursing home” level of care. In this case, the petitioner was enrolled in Family Care with Lakeland as her MCO, had an […] Read more

DHA Case No. FCP 219586 (Wis. Div. Hearings and Appeals Jan. 16, 2026) (DHS) ↓ Download PDF Participants in Family Care have the right to appeal any adverse benefit determination. In this case, the petitioner’s MCO involuntarily ended her ability to self-direct her services and claimed this was not appealable because it was not an […] Read more

DHA Case No. FCP 220397 (Wis. Div. Hearings and Appeals Dec. 29, 2025) (DHS) ↓ Download PDF The Family Care program, through MCOs, must generally provide services that reasonably and effectively address all of the recipient’s long-term needs and outcomes, assist the recipient to be as self-reliant and autonomous as possible, and are cost effective. […] Read more

DHA Case No. HMO 220155 (Wis. Div. Hearings and Appeals Dec. 26, 2025) (DHS) ↓ Download PDF Wisconsin Medicaid does not cover experimental services, a determination the Department makes on its own. In this case, the petitioner requested an Occipital Nerve Block, which was denied as experimental. While recognizing that past decisions have considered experimental […] Read more